The History and Symptoms tab is designed to view, add, remove, and confirm a variety of categories regarding the patient's current health and health history.
We will start by looking at the HPI Narrative and Symptoms sections to see how they work together.
The Narrative section allows you to type or dictate, using Nuance and a computer-connected microphone, any patient visit notes, while Symptoms displays any symptoms the patient may be currently experiencing.
Already provided for us, we see notes from the Nurse and Support Narrative.
Likewise, under Symptoms we see patient symptoms that were confirmed earlier by Nurse and Support staff.
- We can input additional notes at this time, again done either by dictation or typing. When finished, be sure to click Save.
- Upon clicking Save, note how the symptoms list has been updated with the key words provided from the narrative.
- To add additional symptoms to the list, click New.
- Select a box or use the Search for Symptoms field and click Add, then Save.
- You can change the value of a symptom by clicking on the value.
- To remove the symptom from the list, first select the item, then click Remove.
The remaining sections of the History and Symptoms tab are designed to add, confirm, and remove items pertaining to the patient's medical history, and they all function using the same methods.
For example, in the Current Problems section we find a list of all problems the patient is currently being treated for, and options to create a new item, remove an item, confirm an item, and mark an item as Historical.
To add an item to any of these lists, first click New. Search for the item you're looking for, fill out any other relevant information, then click Save.
- All new items added to the patient's chart must be confirmed by a member of the medical team. First, select the item or items, then click Confirm.
To remove an item from the list and from the patient's medical record, select the item and click Remove.
In some cases, we have an option to mark an item as Is Historical. This will remove the item from the list, but will still be associated with the patient's records.
- For example, under the Allergies section first select the item, then click Is Historical. This indicates the patient is no longer affected by the allergy, rather than removing it from the record altogether.
Finally, the Social History section allows you to add additional details regarding the patient's use of tobacco and alcohol by clicking Add More Details.